HYPERTENSION AND RENAL DISEASE

Text Reading Assignment: Essentials of Oral Medicine Chapter 4 - pp. 363641 Renal Diseases and Hypertension

HYPERTENSION (HTN)
Things to know / ask:
What is hypertension? How is it diagnosed? What are signs, symtoms and complications of the disease? How is the disease treated? What are side effects of treatment? treatment? What are the dental implications of HTN? What is the relationship with renal disease? disease? What are the dental implications of renal disease?

What is Hypertension?
Pathologic Disregulation of Blood Pressure (Blood Volume, Vasoconstriction, or Cardiac Output)
Sustained Damaging > 140/90 mm Hg

Primary (90%) and Secondary (10%) (Especially Renal Associated) Types May Affect 20-40 % of Population 20 Definition Dependent % Increases with Age More Common in Blacks and Men Associated with Stress, Weight, Smoking, Diabetes

Blood Pressure
Determining Factors
Cardiac Output: Stroke Volume Heart Rate Force of Contraction
Beta Blockers Calcium Channel Blockers Vasodilators ACE Inhibitors

Peripheral Resistance **

BP

Blood Volume **
Diuretics ACE Inhibitors

Types of Hypertension
100 80 60 40 20 ssential Secondary

90%

Secondary HTN Classification

10%
0

Malignant Hypertension

Renal Ischemia Renin Adrenal Cortical Cushings Syndrome Aldosterone Adenoma Medullary Pheochromocytoma Pituitary ACTH Adenoma

How is Hypertension Diagnosed?

Medical Diagnosis
BP =/> 140/90 (Systolic/Diastolic) 140/90 (Systolic/Diastolic)

Dental Screening / Monitoring

Screen all Patients for Evidence of Disease Refer Knowns and Unknowns for pressures of ~ 140/90 or greater ( 2 successive measurements) Monitor Known HTN Patients for Control

A Relatively Recent Complete Classification

Category Optimal Normal High Normal HTN - Stage I HTN - Stage II HNT - Stage III HTN - Stage IV Systolic < 120 < 130 130130-139 140*140*-159 160*160*-179 180*180*-209 =/> 210 Diastolic < 80 < 85 85-89 8590*90*-99 100*100*-109* 110-119 110=/> 120

* Routine Care OK but Refer for Diagnosis or Improved Managment ** No Elective Treatment without Medical Consult and Improved BP without

What are Symptoms and Complications of Untreated or Undiagnosed Disease?

Symptoms
Usually Asymptomatic (95%) Unless Severe Severe: Dizzines, Ringing in Ears, Headaches, Fainting Spells, Blurred Vision, Epistaxis (Bleeding Nose) or other Prolonged Bleeding

Complications - Undiagnosed or Untreated

Accelerated Atherosclerosis
Increased Risk of Myocardial Infarction (M / Heart AttackI) and Cerobrovascular Accidents (CVA / Stroke)

Congestive Heart Failure (CHF)

Swollen Ankles Shortness of Breath Cough

Small Risk of Eye and/or Renal Damage

How is the Disease Treated?

Life Style Changes
Low Salt Diet Weight Loss Reduced Stress Smoking Cessation

Medication !!!
Diuretics (Decrease blood volume) Vasodilators (Decrease peripheral resistance) Beta Blockers and Calcium Channel Blockers (Decrease Cardiac Output) Angiotensin Converting Enzyme (ACE) Inhibitors (Decrease Angiotensin Formation: Decreased Vasoconstriction and Blood Volume-Aldosterone Volumeassociated sodium retention and blood volume)

What are Side Effects of Treatment of HTN? HTN?

Examples - Systemic
Postural Hypotension (Stand up - Fall Down) Impotence

Examples - Oral
Dry Mouth (Xerostomia) Gingival Hyperplasia (Calcium Channel Nifedipine) Blockers - Nifedipine)

Specific Medication Dependent - Always Check

Questions to Ask in the Medical History How long diagnosed? What medications taking? / Do you take them? / Any recent changes? Any side effects of medications? How well controlled? What is normal with and without medication? Any blood pressure related dental problems?

Things to Do in the Dental Chair

Ask if patient took medication today Check blood pressure before starting appointment Monitor Blood pressure during appointment Be judicious with vasoconstrictor in anesthetic - Dont use retraction cord with epinephrine Remain alert for medication side effects and disease complications

Pertinent Aspects of Medical History Related to HTN

II Have you Experienced (Symptoms)? (Symptoms)?
Chest Pain(Angina) - Atherosclerosis Swollen Ankles - Long Standing CHF Shortness of Breath - Long Standing CHF Cough - Long Standing CHF Bleeding Problems - Severe HTN Dizziness, Ringing in Ears, Headaches, Fainting Spells, Blurred Vision - Severe HTN Excessive Thirst, Frequent Urination / Diabetes Mellitus related HTN - (Atherosclerosis and/or Renal Disease) Disease)

Pertinent Aspects of Medical History Related to HTN

III. Have you Had / Do you Have (Diseases)? (Diseases)?
Heart Disease, Heart Attack Stroke, Hardening of the Arteries High Blood Pressure Kidney Disease Diabetes Mellitus

Pertinent Aspects of Medical History Related to HTN

Are You Taking (Medications)?
Any Medications for Blood Pressure Control
Which Ones? Check for any side effects

Management of Hypertensive Patients

140/90 or Less - No Precautions Needed 141/91 - 160/110 - Sedation? Or Delay > 161/111 - No Elective / Emergency only with Med Consult Controlled HTN: LA Vasoconstrictor OK / Avoid Epi-Retraction Cord Epi Undiagnosed Screening: Retake BP / Refer for Diagnosis

What is Renal (Kidney) Disease?

Inflammatory / Infectious Disease (Usually) that Damages Kidney and Alters Kidney Function
Glomerulonephritis: Immunopathic Disease of Glomerulus (Many SubGlomerulonephritis: SubTypes) Pyelonephritis: Infection of Connective Tissue and Tubules Pyelonephritis:

May Require:

Pyelonephritis

Glomerulonephritis

Medication Dialysis (End-Stage - Renal Failure) (300,000) (End Transplant (End-Stage - Renal Failure) (30,000/yr) (End-

May interfere with:

Drug Metabolism Infection Control and Wound Healing Bleeding (Platelet Adhesion Inhibition)

Chemical Toxins

Kidney
Damage End Stage Renal Dialysis or Transplant

Renal Failure May also be Associated with:

Anemia (loss of erythropoietin) HTN Secondary Hyperparathyroidism (loss of Ca++) ** Uremic Stomatitis ** or Oral Candidiasis Kidney Stones

Developmental Malformations

Secondary Hyperparathyroidism **
Decreased Serum Calcium Increased Parathormone
Calcium removed from bone
Ground Glass Radiographic Appearance or Radiolucent lesions Filled with Giant Cell Granuloma Loss of Lamina Dura

Uremic Stomatitis
Precedes Renal Failure Ammonia in Saliva Oral Ulceration Dysgeusia (abnormal taste): metalic Increased Salivation

The Kidney
Pyelonephritis Glomerulonephritis

Glomerulonephritis - Immunopathic Disease Podocyte Epithelial Cells of Bowmans Capsule with foot processes

Basement Membrane Area Endothelial Cells of Glomerular Capillaries

Antigen / Antibody Complexes Localized or Deposited in Basement Membrane Area Inflammatory Damage to Glomerulus

What is Relationship of Renal Disease to HTN?

Renal Disease may damage the kidney blood supply and activate the RENIN-ANGIOTENSIN system (Release of RENINRenin with ultimate formation of Angiotensin II which raises BP via vasoconstriction and sodium retention) - A form of secondary hypertension HTN may damage the blood supply to the kidney (via accelerated atherosclerosis or arteriolosclerosis) and further contribute to its own progression Altered function may increase Na+ and fluid retention with increased blood volume and pressure

Renin - Angiotensin
Glomerulus and Bowmans Capsule

Juxtaglomerular Cells

Decreased BP Renin Release Formation of Angiotensin Increased Vasoconstriction Increased Aldosterone with Increased Na++ and Fluid Retention

Kidney Disease / End-Stage EndRenal Disease

May Lead to or Cause:
1. Nephritic Syndrome
Blood in Urine (Hematuria), Nitrogen Retention (Azotemia) and decreased urine output (oliguria)

Pyelonephritis

Glomerulonephritis

2. Nephrotic Syndrome
Proteinuria and Hypoproteinemia with Edema (Tissue Swelling)

Kidney
Damage End Stage Renal Dialysis or Transplant

3. Uremia
Decreased Filtration(GFR) and Toxic Elevated Blood Urea Nitrogen (BUN) Chemical Toxins

Kidney Stones

Developmental Malformations

Renal (Kidney) Disease

Questions to Ask
What kind of kidney problem? Does it interfere with everyday living? What Medications ? Are you on Dialysis? Dialysis? Have you had a Kidney Transplant? Transplant? Do you also have HTN? HTN?

Dental Management of Patients with Renal Disease

Avoid Renal Toxic Drugs (Acetominophen) Alter Dosage or Type of Renal Excretable Drugs (Penicillin) Day after Dialysis for Dental Appointments
Best Mental Status and General Health Anticoagulants(Post) and Decreased Platelete Function / Adhesion (Pre) May Interfere with Hemostasis

Increased Risk of Infection for Transplant Patients (Immunosuppression) (Immunosuppression)

HYPERTENSION / RENAL Health History Findings

Uni rsit ft P cific Sc l f ntistr
P ti nt N I. IRC . 2. . . :

General Health Signs & Symptoms Specific Diseases Types of Treatment Medications

EA Yes Yes Yes Yes Yes Yes

5. .

l nk if RO RIATE ANSW ER (l No Is our ener l e alt ood ? No Has t e re e en a c a nge in our e alt it in t e last ear? No Have ou e en o s italized or a d a serious illness in t e last t r ee ears? If Y S , ? No Are ou e ing treated a sician now ? For what? a te of last e dical exam? a te of last e ntal exam No Have ou had r oblems with r ior dental treatment? No Are ou in a in now?

S c. S c. N .: irt t : not n derst nd q e stion):

5 . 57. 58. 59. 0. . .

Recreational drugs? Drugs, medications, over-the-counter medicines (including Aspirin), nat ural remedies?

Please list:

Are you or could you be pregnant or nursing?

To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. Patients signature: RECA Date:

REVIEW : Date: Date: Date:

. Patients signature

2. Patients signature

. Patients signature

VII. A PATIENTS: 7. Yes No If so, please explain:

Do you have or h ave you had any other diseases or medical problems N T listed on this form?

11

VI. W OMEN ON Y: 5. Yes No

01 '1

V. ARE YOU TAKING: . Yes No 2. Yes No

IV. DO YOU HAVE OR HAVE YOU HAD: 5 . Yes No Psychiatric care? 52. Yes No Radiation treatments? Yes No Chemotherapy? 5 . 5 . Yes No Prosthetic heart valve? 55. Yes No Artificial oint?

0 0 0 10 0 00 '0 0 #0 0

III. DO YOU HAVE OR HAVE YOU HAD: 29. Yes No Heart disease? 0. Yes No Heart attack, heart defects? . Yes No Heart murmurs? 2. Yes No Rheumatic fever? . Yes No Stroke, hardening of arteries? . Yes No High blood pressure? 5. Yes No Asthma, TB, emphysema, other lung diseases? . Yes No Hepatitis, other liver disease? 7. Yes No Stomach problems, ulcers? 8. Yes No Allergies to: dru gs, foods, medications, latex? 9. Yes No Family history of diabetes, heart problems, tumors?

0. . 2. . . 5. . 7. 8. 9. 50.

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No No No No No No No No No No

AIDS Tumors, cancer? Arthritis, rheumatism? Eye diseases? Skin diseases? Anemia? VD (syphilis or gonorrhea)? Herpes? Kidney, bladder disease? Thyroid, adrenal disease? Diabetes? Hospitalization? Blood transfusions? Surgeries? Pacemaker? Contact lenses? Tobacco in any form? Alcohol?

Yes

No

Taking birth control pills?

1 0 ' #

# #

II. HAVE YOU EX ERIENCED: 7. Yes No Chest a in (angi na)? 8. Yes No Swollen ankles? 9. Yes No Shortness of breath? 0. Yes No Recent weight loss, fever, night sweats? . Yes No Persistent cough, coughing up blood? 2. Yes No Bleeding problems, bruising easil ? . Yes No Sinus problems? . Yes No Difficult swallowing? 5. Yes No Diarrhea, constipation, blood in stools? . Yes No Frequent vomiting, nausea? 7. Yes No Difficult urinating, blood in urine?

8. 9. 20. 2 . 22. 2 . 2 . 25. 2 . 27. 28.

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No No No Dizziness? Ringing in ears? Headaches? Fainting s e lls? Blurred vision? Seizures? Excessive thirst? Frequent urination? Dr mouth? Jaundice? Joint pain, stiffness?

( ( (     ( % %  )    (  %&   &   %    ! ! " !  $   $       

HEA TH HI T ORY

0 ' #         44  # # 1# # 0# '# ## # 0 ' # 5 ' ' ' 1' ' 0' '' ' #' ' 1 #1 1 1 1 6

Go To Health History

HYPERTENSION / RENAL UOP Protocols

University of the acific chool of Dentistry

See:
Questions to Ask Diagnostic Tests Dental Management Alerts (Complications)

rotocols for the

DENTAL M ANAGEM ENT OF M EDICALLY COM PLEX PATIENTS

TOPIC 1. Bleeding Problem s (including anticoagulants) 2. Cardiac Problem s (heart m urm urs, cardiac defects) 3. Cardiovascular Problem s (high blood pressure, arrhythm ias) 4. Central Nervous System Problem s (seizures, stroke) 5. Diabetes 6. Im m unosuppression 7. Infectious Diseases (tuberculosis, hepatitis, HIV, herpes, flu) 8. Kidney Problem s 9. Liver Problem s 10. Pregnancy 11. Prosthetic Joints
r otocols com piled by: e ter L. Jacobsen, h .D ., D .D . D epartm ent of a thology and M edicine

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lease direct all com m ents, edits and suggestions to him at: pjacobse@ uop.edu or call (41 ) -66 or fax (41 ) -66 4 or w rite to: D epartm ent of a thology and M edicine UO chool of D entistry 1 W ebster treet an r ancisco, C A 411

Go To UOP Protocol

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THE END